Pain with sex after giving birth is common. According to the American College of Obstetrics and Gynecology 75% of women experience painful intercourse at some point in their lives. For many women, myself included, this can occur during the postpartum phase when our bodies have hormonal shifts. Sometimes the pain lingers well past the fourth trimester, as it did with me.
I know this is an uncomfortable topic to discuss. I’m feeling self-conscious just writing this post. But I believe it’s so important that we say aloud, “I’m not okay,” when it comes to our sexual health, and that we get the care we deserve.
Several types of providers who can help, which is great news. And the field of sexual health and sexual medicine is growing. In the coming months I’ll discuss this topic from many perspectives, asking different practitioners how they help women like us.
To start off this series on postpartum sexual health, Jenna Perkins—Women’s Health Nurse Practitioner (WHNP) at George Washington University Hospital, in DC—answered a bunch of questions I had about postpartum pain with sex. I started seeing Jenna earlier this year and she is a wealth of information and passionate about her work.
Here’s our conversation.
*This interview has been edited for length and clarity*
Yuka: How common is your specialty in pelvic floor issues?
Jenna: I don’t know many other people who are doing the role that I’m doing. There was a WHNP who was working in DC who helped to train me but she was doing just sexual dysfunction, she wasn’t doing the urology piece. But everything is connected. My patients don’t just come with incontinence. They come with incontinence and recurring vaginal infections, and painful intercourse, and fecal incontinence. Everything is so related that I found it hard to deliver quality care without addressing all those pieces.
Y: What are the most common issues you see among postpartum women?
J: Postpartum is an interesting period because so many things are transitioning in the body. You have hormonal changes that are occurring. [These] women are hypoestrogenic, so you don’t have quite enough estrogen feeding the tissue and that can lead to dryness, especially if you’re breastfeeding.
Hormones can change the skin of the vulva and the vagina. If they are dry, they can atrophy and you can lose the architecture that’s there so things start to look a little bit different. The tissue can become weaker without those hormones. So you can have an increased incidence of something called pelvic organ prolapse because that tissue support isn’t there.
The other piece is muscular, which can also cause prolapse. If those muscles are weak, you can have a herniation of the organs: the bladder, the rectum, the uterus. They can actually come into the vaginal canal and sometimes out of it. It’s usually a combination of all three: hormones, muscles, and skin where you see most of the issues in the postpartum phase. And they are all very connected. The hormones can lead to dryness, which can lead to skin changes. The hormones can lead to the tissue weakness, which can further along any muscle dysfunction that’s happening with the prolapse. But those are the big three categories.
Y: Specifically with sex, what are some of the big issues that come up with the women that you see?
J: So in the postpartum phase, things have shifted and with the dryness you’re more prone to having urinary tract infections (UTI). I see a lot of postpartum and breastfeeding moms who have recurrent UTIs. One of the best things to do, if you’re experiencing UTIs in the postpartum phase and you’ve returned to sexual activity is to make sure you’re using lots of lubricant because that friction of having intercourse can make you more prone to UTIs.
Y: Any kinds of lubrication?
J: I have some personal faves. The KY jelly, the stuff you can just grab off the shelf at CVS, usually are not the best.
Y: Why is that?
J: I usually look for natural ingredients on the label. You want to keep it minimal with ingredients because the more ingredients you have the more chemicals, and if you’re in this phase where your tissue is already so sensitive, the slightest little thing can be burning and irritating. Some of the jellies are made with alcohol, so they might feel very slippery for the first minute or so and then you get even more dry than you were before because of the chemicals in them. I do have some faves and samples in the clinic that I can give to patients but it’s really what floats your boat as long as it has minimal ingredients. There are lots of great lube out there on the market.
Y: Is it normal for sex to be painful after you give birth?
J: I think you can expect some discomfort, but pain is subjective. Pain has the connotation that it’s not enjoyable. So, if you have a little discomfort but you’re still enjoying it, go ahead and do your thing. But if it’s painful and it’s causing you distress then I would recommend not pushing through it. You should never have pain. You can expect discomfort. A lot of things have shifted, your muscles can be tighter than they were before, skin can be more dry.
Society can lead us to believe that pain with sex or lack of interest is an expectation for women, and so many women feel guilty about it and don’t want to talk to their providers. Or when they do come into for their 6-week postpartum, or a couple months after, and things still don’t feel good, they can be “poo-pooed” on. The issue is not really addressed to their satisfaction and that can be discouraging.
Y: So how would a woman who is experiencing pain find a provider like you, especially if they’re being dismissed by their providers who act as gatekeepers to specialized services?
J: That’s a really good question. For me, now that I’m part of the OBGYN department, you usually don’t need a referral to see me. A lot of people can find me. If you google, “Jenna Perkins” in zocdoc, my page will show up so you can schedule with me right away for women who are in the metro DC area.
For other people, I would suggest, if you’re having chronic painful intercourse that you check out ISSWSH.org (pronounced ish-wish). It’s the International Society for the Study of Women’s Sexual Health. It’s a multidisciplinary group. We have nurse practitioners (NP), mostly in women’s health, some family NPs, lots of urologists, lots of OBGYNs. But anybody who’s a member of this society and has gone to a few of their conferences has more knowledge then a general GYN or a midwife. I would suggest finding a provider from them. That would be the easiest way to go about making sure that you find someone who has had quality training to really address your issues.
There’s another website, NVA.org. This is the National Vulvodynia Association (NVA). Vulvodynia is a diagnosis that means you have pain in the vulva. It’s just an umbrella term. Usually, women who have painful intercourse will fall under the diagnosis. NVA has done a really good job at putting out resources for patients. You can also find a health care provider list, on their website.
Y: Can you explain some of the specifics of why painful intercourse happens? I know it can vary from women to women.
J: It goes back to those three main things. Muscle dysfunction: tightness of the pelvic floor. Or sometimes it’s idiopathic, which means that we don’t have a rationale or a reason for it. The skin: dryness can cause things to be painful. And the last thing is hormones: sometimes, simply being on birth control (BCP) can shift your hormones and cause a lot of the pain you can experience in the postpartum period.
Y: Even with women who aren’t on birth control and aren’t in the postpartum phase, can they still experience pain as well?
J: Absolutely. A few major [times] for being in a hypoestrogenic state. One is being a new born, where you don’t quite have the hormones yet. So, if you were to look at the vulva of a baby girl, it could be red, irritated, chapped, dry. So, prepubescent is one area. Another time is when a woman is on the BCP. However old you are, you can have issues if you’re on the BCP and it shifts your hormones. The next big hormone phase is postpartum and breastfeeding. So, that definitely changes your estrogen levels. And the final one is menopause. You can find similar issues in all of these phases where you have recurrent infections, vaginal or urinary burning, pain, things like that.
Y: Why do you think it’s important to address these issues of painful sex after childbirth, and generally?
J: I think it’s because women deserve to have a healthy functioning sexual life the same way as other human beings. Sexual function is at the core of who we are as people. Literally, without sex, you would have no humans. I think it’s really one of the basic things to human life and women deserve to have some enjoyment out of that. And it shouldn’t just be a chore to bear children.
We should be able to enjoy ourselves. To have that sexual freedom is a right that every woman deserves, should she choose it. It should be an option. If you don’t have a particular interest in being sexually active then that’s okay. But if you do, and you have pain, that ties your hand and prevents you from having that choice of being a sexual being. Human beings are very sexual. When you walk outside you see sex everywhere but we don’t talk about the real things that are happening to a lot of women, when it comes to having healthy sex lives. I think the feminist in me is like “we deserve this.” And if we can give out Viagra for guys, then we should be getting something too to help us.
Y: Thanks Jenna for the work you do.
J: Thank you too.
**Jenna has an Instagram account where she shares her knowledge of women’s health and urogynecology. Follow her @discovherhealth